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Monday, July 20, 2015

Why dogs should avoid the hor d'oeuvres: the tale of a migrating toothpick

These, I am told, are "devils on horseback". A plate like this, left unattended, can easily turn into "devils inside a dog".

Reading a decent case report is like reading a great
detective story, with the added bonus of learning something you might use in
practice.

In this month’s issue of the Australian Veterinary Practitioner there is a case report, modestly
entitled “Toothpick as a perforating splenic foreign body in a dog:
ultrasonography diagnosis and surgical treatment”. Some of you might have tuned
out half way through the title, but this little tale contains some very
important lessons for dogs and those who live with them – as well as their vets.

Let me paint the picture for you. A five-year-old, 8.5kg male dachshund, kept
indoors with another dachsy, is a much loved companion. The owner dotes on the
dogs and I would imagine these dogs are the kind who are ever-present when one
is preparing meals or hor d’oeuvres for special occasions.

But this poor dog develops diarrhoea, which continues for
about two months. There is occasional vomiting and abdominal pain. It’s one of
those cases where they have good days and bad days, the signs are occasionally
subtle, sometimes more dramatic, but nothing to write home about.

The regular vet, concerned there might be something more
sinister going on (perhaps pancreatitis) refers the dog for an abdominal
ultrasound. The dog has peritonitis – an inflamed abdomen containing free
fluid, which was sampled and contained bacteria and inflammatory cells.
Ultrasound is very good for detecting fluid, but when there is a lot of fluid
it can mask some things that would otherwise be visible.

No diagnostic test is 100 per cent perfect, none
guarantees a definitive diagnosis and far too often in a veterinary context we’re
reluctant to repeat a test, instead moving up the diagnostic ladder.
Fortunately, after some fluid was drained, the ultrasound was repeated. The culprit,
previously hidden by a volume of fluid, was immediately visible: a toothpick
sitting in the spleen.

How does a toothpick get into a spleen? One of two ways.
One either falls on that toothpick with such force that it is rammed through
the skin and lodges into the organ, although you’d imagine there would be an
obvious wound or tract. OR one swallows the offending toothpick which, with its
pointy tips, simply perforates the stomach and goes a-wandering around the abdomen
until it lodges somewhere else.

Pointy foreign bodies can migrate, I found this kebab tip in a skin abscess in a dog that had nibbled on a kebab several months prior.

Once the toothpick was sited, the owner vaguely recalled
a possible window during which the dog might have ingested the toothpick –
around two months ago. That explains the chronic signs.

Foreign bodies – particularly those that don’t obstruct
the gastrointestinal tract – can be very tricky to diagnose. They can cause
intermittent, waxing and waning clinical signs. Bloodwork may be unremarkable. Wood
and plant material, including toothpicks, don’t show up very well on
radiographs.

There are several morals to the story.

Be very wary when using toothpicks or those sharp wooden
kebab skewers anywhere in the vicinity of a canine (and remember that dogs don’t
mind going through the trash after you have a party, and toothpicks are the
sort of thing that perforate garbage bags so are easily sited and removed by
dogs).

If you detect evidence of inflammation in the thorax or abdomen,
consider a migrating foreign body as a possibility.

Ultrasound is an important diagnostic step for
identifying the cause of abdominal pain, but it might have to be repeated.

Fortunately for this patient the diagnosis was the tricky
bit. Once that was achieved the surgery was (relatively speaking) a piece of
cake. The toothpick was easily located and very gently extracted from the
spleen by simply pulling it out. There was no major haemorrhage and certainly
no need to remove the spleen. The abdomen was lavaged (washed with sterile
saline) and he made a complete recovery.

Veterinary Ethics: Navigating Tough Cases

WARNING

All images and content on this site are copyright Anne Fawcett unless stated otherwise and should not be reproduced without written permission. Please be aware that some surgical and clinical images are used on this site.